1548997372 NPI number — MAXIMUM IMPACT PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548997372 NPI number — MAXIMUM IMPACT PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXIMUM IMPACT PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548997372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5604 PLANETA CT NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87111-1416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-363-4038
Provider Business Mailing Address Fax Number:
505-393-3955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10555 MONTGOMERY BLVD NE STE 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87111-3857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-336-4254
Provider Business Practice Location Address Fax Number:
505-393-3955
Provider Enumeration Date:
08/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
MESCH
Authorized Official First Name:
SHYLA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
505-363-4038

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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